Fraser Health aims to divert elderly back home from hospitals

Fraser Health is stepping up efforts to steer seniors away from costly hospital or long-term care beds if they can be supported and treated in their own homes.

The health authority has hired five quick response case managers – based at Royal Columbian, Surrey Memorial, Burnaby, Abbotsford Regional and Peace Arch hospitals – to work with geriatric nurses to flag incoming patients at ERs who can instead be sent home with bolstered supports.

That’s one of a series of initiatives underway collectively dubbed “Home is Right” – a broad effort to change the mindset of hospital officials, health care workers and families.

“Home with appropriate supports – not hospital, not residential care – is the best place for seniors to manage their chronic conditions and live out their final days,” says Lynda Foley, Fraser Health’s executive director of home health and end of life care.

Most seniors prefer to stay in their own homes, with their pets, belongings and family.

They have what they need, can be more active and social, and they avoid the risks of hospital-borne infections.

Parked in a wheelchair or stretcher in hospital, they can quickly lose muscle strength and typically take longer to recover.

And hospitals will simply hit a breaking point as the demographic bulge of seniors grows if the chronically ill elderly continue to be primarily handled by the acute care system.

“We know that tsunami is coming at us,” Foley said. “If we don’t change the system, we’re not going to be able to sustain it into the future.”

The trick is to deliver needed supports into homes.

Foley said that strategic shift is underway and has been gaining momentum since January, when Fraser Health formally set home care as the first option to be considered for elderly patients who no longer need a hospital bed.

She gives the example of an 85-year-old man who arrives at hospital with symptoms from his end-stage heart disease.

He might not be admitted but instead diverted from the ER back home where whatever care is needed can be arranged.

The quick response care manager who made that decision would actually accompany him home, check his medications, assess the situation and arrange follow up care by a family doctor, geriatrician and other support staff – coordinated by a community case manager.

Other patients who must be admitted to hospital because of more serious symptoms can be stabilized and then shifted more quickly back to home if the necessary supports are there.

The region has already increased home support service by 11 per cent over the past year, to 169,000 hours a month.

The region is hiring more home support workers, who can help with grooming, bathing and managing medications.

Physiotherapists, nurses and other professionals can be dispatched to the home to provide treatment and ensure the home is safe.

Eight more home health liaisons have also been added to hospitals – they check on admitted patients daily to determine which ones can soon be discharged and start arranging home support services.

Put together, officials are betting the Home is Best strategy will cut wait times for residential care and free up hospital beds for the patients who most need them.

The shift to home has been talked about for years, but Foley says much more support is now in place than in the past.

They include programs like seniors day care, which might let an elderly woman taking care of her much more ill husband get a few hours break to pay the bills, shop or take time for herself.

Longer term respite care could even let her take a vacation.

Home care spending in Fraser Health has swelled to nearly $200 million a year, providing some kind of care or service in the home to 15,000 people daily.

Some services are free, while in other cases patients pay fees based on income or are billed for supplies.

Foley is ready for skeptics who may think the diverted seniors will end up under-treated in the name of saving the system money.

“I believe the system has to step up and flex its muscle and show we can do what we want to do,” Foley said.

Dr. Grace Park, medical director for Fraser’s home health program, says the redesign of services underway should ensure seniors feel supported and safe living at home.

“Families often worry that their elderly loved one is too frail to live at home and should go to a residential care facility,” Park said. “They need confidence that adequate community and home support programs will be there and that their care will be coordinated by the health care team.”